Health inspection·November 21, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for, 1 of 1 resident (Resident #1) observed for infection control issues in that: CNA A did not follow infection control procedures while providing incontinent care to Resident #1 when she failed to apply a PPE gown prior to providing incontinent care, reused wipes when providing care to the perineal area, and did not sanitize hands between glove changes. This deficient practice could place residents at-risk for infection due to improper PPE, sanitizing hands, and incontinent care practices.The findings included: Record review of Resident #1's electronic face sheet dated 11/5/25 revealed the resident was a [AGE] year-old female with an initial admit date to the facility on 7/16/25. Her diagnosis included dementia (a medical condition characterized by a progressive decline in cognitive functions, such as memory, thinking, reasoning, language, and judgement), depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest), dysphagia (a medical condition characterized by difficulty or discomfort in swallowing), cognitive communication deficit (an impairment in a person's ability to communicate effectively due to underlying problems with cognitive functions like memory, attention, reasoning, and problem-solving), nontraumatic intracerebral hemorrhage (a type of stroke involving bleeding within the brain's tissue that was not caused by a physical injury), unspecified convulsions (sudden, involuntary muscle contractions or spasms where the exact type or cause was not identified), muscle weakness, muscle wasting and atrophy (decrease in size or wasting away of muscle). Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected Resident # 1 had a BIMS score of 10 which indicated moderate cognitive impairment and was dependent for all ADL care. Record review of Resident #1's undated comprehensive person-centered care plan, reflected Resident #1 had:ADL Self Care Performance Deficit r/t Weakness. Dx. CVA w/Lt. Hemiplegia. intracranialhemorrhage, dementia. TOILET USE (TOILET TRANSFER, TOILET HYGIENE): requires assistance to: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet, to use toilet. Date Initiated: 07/17/2025.Had Indwelling Catheter. Catheter type: FR # 18 mL _ to closed urinary drainage system - diagnosis for use: neurogenic bladder Date Initiated: 07/17/2025. Use Enhanced Barrier Precautions Date Initiated: 07/24/2025.Requires tube feeding Glucerna 1.5 AT 50 ML/HR X 22 hr, 200ml water q 4 hours Date Initiated: 07/17/2025. Use Enhanced Barrier Precautions Date Initiated: 10/07/2025Had pressure ulcer or potential for pressure ulcer development r/t Risk for skin integrity. Weakness. Dx. CVA w/Lt. Hemiplegia. intracranial hemorrhage, dementia, DMII. malnutrition,Actual pressure ulcer: stage 3 pressure ulcer to sacrum Date Initiated: 09/09/2025 Created on: 07/17/2025. Use Enhanced Barrier Precautions Date Initiated: 08/31/2025EBP PPE Risk for infection related to High contact care activity Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: indwelling Residents Affected - Few Page 1 of 4 676042 676042 11/21/2025 McAllen Transitional Care Center 2109 South K St MC Allen, TX 78503

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few catheter, PEG tube, wounds. Date Initiated: 11/05/2025. Record review of Resident #1's Order Summary Report dated 11/5/25 reflected orders for Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: Indwelling catheter, PEG Tube, wounds every shift Active 10/7/2025. During an incontinent care observation for Resident #1 on 11/4/25 at 5:45 PM., CNA A performed incontinent care on Resident #1, LVN B was already in the room and later assisted with repositioning and providing safety for Resident #1, and ADON C was already in the room at the time the need for a brief change was identified and remained in the room. CNA A appropriately washed her hands and donned gloves prior to starting incontinent care. CNA began incontinent care when unfasted the tabs on the brief, opened the diaper forward, when noted Resident #1 had a large BM that entered the vaginal area. CNA A wiped the vaginal area using one wipe per swipe. CNA A did not apply a gown prior to starting incontinent care. CNA A removed her gloves after swiping with the second wipe, then washed her hands with soap and water in the bathroom sink. CNA A returned wearing a gown and clean gloves. CNA A continued to wipe the vaginal area using one wipe per swipe until the vaginal area was cleaned. CNA A would wash her hands with soap and water after every second glove change. CNA A did not sanitize her hands between the other glove changes. CNA began using one wipe per swipe when she cleaned the buttocks area, but after the third wipe CNA folded over each wipe and reused each wipe throughout the remainder of the incontinent care. In an interview on 11/4/25 at 6:20 pm., CNA A stated they received skills check-off and/or training on incontinent care every couple of weeks. She said they also cover this information during monthly meetings. She said the DON was very good at providing training and keeping staff up to date with everything. CNA A said she was supposed to use gloves and a gown when providing incontinent care to Resident #1 because she had a foley catheter, but she forgot to place it on at first because she was so nervous. CNA A said it was also the largest BM Resident #1 had. CNA A said that was why she washed her hands when she completed her first wipe, and she applied the gown at that time. CNA A said she should be using hand sanitizer to sanitize hands every second glove change. She should use hand sanitizer or wash hands. When this surveyor asked CNA A if she should be using hand sanitizer in between each glove change, CNA A said no, it was never the second glove change. CNA A said while providing incontinent care, she could reuse a wipe as long as she folded it over and used a clean part of the wipe. CNA A then changed her response and said she remembered she could hand sanitize every glove change and wash hands every 2nd or 3rd glove change. She said she only remembered using hand sanitizer once between glove changes during incontinent care, but then did not use hand sanitizer again between glove changes for the remainder of the incontinent care. She said she was very nervous. She said if she did not provide incontinent care correctly, it could cause infections. In an interview on 11/4/25 at 6:35 pm, LVN B stated she recalled receiving training, and skills check offs for incontinent care and infection control upon hire and usually had trainings weekly or monthly. She said she recalled having one a couple of weeks ago. She said they trained both CNAs and nurses. She said they must wear gloves and a gown during incontinent care for Resident #1 because she was EBP due to having a foley and a PEG tube. LVN B said that was why she placed the gown on when she was asked to assist with the incontinent care for Resident #1. LVN B said they must perform hand hygiene before and after care and when hands were visibly soiled. LVN B said hand sanitizer should be used between glove changes and that they changed gloves and sanitize or wash hands at the beginning and end or when visibly soiled. She said if appropriate hand hygiene and PPE were not used, they could break infection and possible spread of germs. In an interview on 11/4/25 at 6:55 pm, ADON C said she assisted with incontinent care and infection control training and the DON oversaw. She said they had a station with mannequins where they could practice when needed. ADON C 676042 Page 2 of 4 676042 11/21/2025 McAllen Transitional Care Center 2109 South K St MC Allen, TX 78503

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said they went over information during huddles one or twice a month and had videos available to review. ADON C said the DON completed the skills training and check-offs for the staff. ADON C said they go over PPE, and get them to understand when they should be utilized and the reason residents had them. ADON C said Resident #1 was on EBP due to having a foley and peg tube. ADON C said staff must wear gowns and gloves when providing incontinent care with Resident #1. ADON C agreed that CNA A had not put on a gown when she began providing incontinent care to Resident #1. She said CNA A applied the gown after she recalled. ADON C said staff must change gloves when they were visibly dirty, and when touching residents. ADON C said hands should be sanitized in between glove changes. ADON C said hand washing must be done after every third time they sanitized hands and/or change gloves, before starting care and after finishing care. ADON C said wipes were supposed to be used by swiping once then tossing them in trash. ADON C said if proper hand hygiene and PPE were not utilized it would break infection control. In an interview on 11/5/25 at 10:06 am, the DON said infection control was included in monthly meetings. The DON said they had nursing huddles twice a month. He stated huddles were like in-services, so they received signatures, and he also provides power points. He said during the training, he goes over hand hygiene, EBP, different types of isolations, proper handling of linen, dos, and don'ts of breaking infection control. The DON said he completes check-offs on skills annually. The DON said he also reinforces it during open window for survey. He said they had their internal audit in September and part of what they completed was the skills check-offs. The DON said they go over hand washing monthly, and he had a list he keeps track. The DON said he also monitored EBP and PPE usage. The DON said hand hygiene must be done before incontinent care with soap and water for at least 20 seconds. He said in between, they can use hand sanitizer or wash hands if they feel their hands were soiled. He said staff were told that they must hand sanitize between glove changes. The DON said staff must also perform hand hygiene after incontinent care was done. The DON said regarding wipes, staff were told to clean from clean to dirty, preferably with enough supplies to use the one wipe technique. The DON said if the wipes were not dirty, they can fold and use a clean area of the wipe, but not more than two folds per wipe, then staff must dispose of the wipe. The DON said he did not feel it was a break in infection control if it was used in the same area. The DON said they used larger wipes that had a larger surface area. The DON said if heavy soiled during peri care and used the wipes then yes should dispose of the wipes after use. The DON said Resident #1 was on EBP because of her PEG tube, foley catheter, and pressure ulcer. The DON said PPE for EBP was only for direct contact of care not for other tasks, such as combing hair or providing water. The DON said for incontinent care they must wear gloves and a gown prior to starting care for Resident #1. The DON said the whole purpose was to stop the spread of infection, prevent it from getting and spreading, or minimize the spread of infection. The DON said the CNA not placing the appropriate PPE prior to starting incontinent care on Resident #1 could start a mode of transmission of anything Resident #1 could have had. Record review of Resident Nurse Assistant Skill Inventory Checklist for CNA A dated 6/17/25 Perineal indicated CNA met skills for:Standard Precautions, Isolation Precautions / Use of PPE, Glove Use (Donning (put on) / Doffing (remove)), Hand Hygiene, Perineal Care for the incontinent female, and Indwelling Urinary Catheter Care and was signed and dated by the DON. Record review of the facility's IPCP Standard and Transmission-Based Precautions with most recent revision/review date October 2022 revealed:PolicyIt is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions.3. Enhanced Barrier Protection (EBP): expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing 676042 Page 3 of 4 676042 11/21/2025 McAllen Transitional Care Center 2109 South K St MC Allen, TX 78503

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few then indirectly transferred to residents or from resident-to-resident. (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs).a. PPE: The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with:i. Wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents.c. Examples of high-contract resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: vi. Changing briefs or assisting with toileting viii. Wound care: any skin opening requiring a dressingix. In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to Standard Precautions. Record review of the facility's Hand Hygiene policy with the most recent revision/review date April 2025, revealed:PolicyIt is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards. Residents, family, and visitors will be encouraged to practice hand hygiene. Procedure1. Wash hands with soap and water for the following situations: a. When hands are visibly soiled (e.g., blood, body fluids) .2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; . e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites); . h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin; j. After contact with blood or bodily fluids; . m. After removing gloves; . r. After removing and disposing of personal protective equipment Record review of the facility's Incontinent Care policy with most recent revision/review date 4.2025, revealed:PolicyIt is the policy of this facility that each resident receive perineum cleansing after incontinent episode daily and as needed (PRN) to promote hygiene, comfort, and decrease the risk of infection. Procedure1. Gather equipment and supplies. a. Soap or cleanserb. Basin with water (disposable wipes may be used as a substitute for soap and water)c. Glovesd. Two clean washcloths(more if needed and trash bag .FEMALE - WITHOUT CATHETER11. Cleanse pubic area, including upper, inner aspect of both thighs and frontal portion of perineum. a. Use long strokes from the most anterior down to the base of the labia. (Wash from the cleanest area to the dirtiest area.) b. After each stroke, Use a clean portion of the disposable wipe for one cleansing motion.14. Wash perineal area thoroughly, with each stroke beginning at the base of the labia and extending up over the buttocks. a. Use a clean portion of the disposable wipe for one cleansing motion.FEMALE - WITH CATHETER16. Moisten the washcloth and apply soap to the washcloth or using moistened disposable wipes, clean the catheter in a downward motion (front to back) beginning at the urinary meatus (insertion point) and at least 4 inches down (from resident toward the collection bag). Use a clean portion of the disposable wipe for one cleansing motion. 676042 Page 4 of 4